Provider Demographics
NPI:1750637740
Name:KOVALEV, VITALEY (PA-C, DO)
Entity Type:Individual
Prefix:
First Name:VITALEY
Middle Name:
Last Name:KOVALEV
Suffix:
Gender:M
Credentials:PA-C, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 S SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-4830
Mailing Address - Country:US
Mailing Address - Phone:323-578-5451
Mailing Address - Fax:
Practice Address - Street 1:10100 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-4830
Practice Address - Country:US
Practice Address - Phone:323-578-5451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03549363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical